"Think in the morning, act in the noon,

eat in the evening, sleep in the night."

--William Blake

Chapter 8

Eating and Sleep Disorders

Dale L. Johnson

Eating Disorders

Eating is universal among living creatures. It is necessary to sustain life. Furthermore, it is a fairly simple process. As to what is eaten, humans are omnivores and are able to eat almost anything organic. So what is the problem? There really isn't much of a problem if one's situation is such that getting barely enough to eat each day to survive is the issue. One eats what one can when one can. The problems for abnormal psychology seem to develop in conditions where food is ample.

Over time, social customs have developed to guide, or regulate, eating practices; the number of meals, size of meals, when, with whom, and what is eaten. Diet has been determined by what kinds of food are available. Thus, the rural, coastal Norwegian family of the 1800s ate cod fish, potatoes and rye bread. Eskimoes ate high fat diets of seal and fish. The Mazahua of central Mexico ate fruits and vegetables, with chicken or pork reserved for feast days. The diets of most of the people on earth are largely vegetable. Today, with even modest incomes we have an enormous array of foods available to us. Custom has less to do with our eating habits and personal choice is much more prominent. Some people by choice are vegetarians, and here there is a range of meaning. By contrast, I know a man who eats only meat, and has since he was a child.

Americans as a society are overweight, by their own standards of proper weight. It is striking to contrast Americans with people of other worlds. There are virtually no obese people in the Chimalapa forest of southern Mexico. Most Africans and Asians are not obese, unless they are wealthy. In American it is the opposite: the poor are obese, the rich are not, especially for women. Tanner, a distinguished physical anthropologist, said the inverse relation of wealth and weight is so solidly established that one could confidently predict that Howard Hughes, at the time America’s wealthiest man, would have no wife at all (little joke there). It is also interesting to note the differences in weight between Americans and Europeans such as the Dutch. Few young Hollanders are obese, but that cannot be said for Americans. Dutch children do not ride buses to school, they walk or ride their bicycles.

These observations lead to several conclusions. Americans eat a great deal of high fat foods, we consume more calories overall, and we do not engage in natural exercise. In the United States, the people of Oregon, Washington and Utah are most lilely to excercise and the citizens of South Dakota, Arizona, Oklahoma and most of the Southern states are least likely to exercise (Center for Disease Control, 2001).

At the same time, we are exposed to media depictions of slim being beautiful. TV has its fat people such as Roseanne and before her, Jackie Gleason, but they were comics. Other fatties have tragic roles. It is more likely that a heavy weight man will be depicted as competent and compassionate (cop on NYPD Blue) than a heavy weight woman (I cannot think of any). This exposure is not so recent, having come with movies and then on to television, but there has been a steady trend toward idealizing the slender.

These social factors set the stage for a series of problem behaviors. How can one freely choose what and how much to eat and still maintain an ideal weight and shape? How these circumstances lead to major eating disorders is a more complex question.

Definitions

Anorexia Nervosa--refusal to eat only minimal amounts of food.

Bulimia nervosa--attempts to control food intake results in out-of-control eating episodes, binges.

Both disorders associated with a desire to be thin. The seriousness of these disorders can be appreciated by knowing that the death rates are very high--20% die, many by suicide.

There has been a rapid increase in the number of cases, especially for bulimia.

The disorders appear to be culturally specific. They are found only in developed countries where access to food is not an issue. 90% of cases are young, white, middle to upper SES living in a competitive environment.

Bulimia Nervosa

Binge/purge episodes. See the example of Phoebe in the textbook.

How much eating is a binge? We need to quantify and tp be specific to cut through the denial and misconstruction of the actions.

1. How much did people eat?

27% ate 2000 calories

33% ate 600 or fewer calories.

The average was about 1500 calories as contrasted with 321 calories for non-binge eating.

2. Quality of the eating. It is best characterized as out-of-control. The person has a sense of hopelessness or of learned helplessness.

3. Purge-type. 2/3rds of bulimics are purgers. There is more psychopathology with purgers. Are they more desperate?

4. View of self. Irrational: "I must have a body that everyone sees as beautiful." This view was held by 97% of bulimics. Of course, this standard of personal beauty is nonsense, but that is what makes it irrational.

Physicians can uncover most cases of bulimia with two simple questions: 1) Are you satisfied with your eating patterns? and 2) Do you ever eat in secret? If the answer is "no" to the first and "yes" to the second, there may be trouble.

Anorexia Nervosa (AN)

This is not a new disorder. It was first named in 1870, and the first photo of a person with anorexia was in 1932. Treatment at the time was in psychiatric hospitals and included forced feeding, dynamic psychotherapy, and environmental change.

There are several differences between anorexia nervosa and bulimia. Most bulimics are within 10% of expected body weight and people with anorexia are not. Bulimia is also more common. The two disorders are not entirely separate: many people with bulimia have had some anorexic episodes.

Clinical Description of AN

The central issue in AN is an intense fear of obesity, and with that, a pursuit of thinness. The person checks the body in the mirror to look for evidence of fat.

People with AN experience eating as a fat-making process. They commonly report feeling bloated, too full, even after conventional meals. They have difficulty with other feelings as well; feelings such as fatique and anger..

Binge/purge anorexics are often involved in more impulsive behaviors; shoplifting, alcohol, and self-mutilation. They tend to be mildly depressed and to have low self-esteem. Sleep disturbances are common. Obsessive compulsive behaviors (OCD) may be present. e.g., preparing meals according to rigid rules. OCD and AN had similar scores for obsessiveness in a 1982 study. Furthermore, people with AN were

More likely to be obese as children.

More likely to come from families with obesity.

More often ballet students or fashion models.

More like to see themselves as fat and to be resistant to pleas by others to gain weight..

More likely to set a diet for themselves of about 600 to 800 calories per day instead of a more reasonaable 1800. They are also in constant motion, with more activity in general. They become obsessive about exercise and will not skip a minute of an exercise routine.

More likely to develop a preoccupation with food. They say they like to cook for others.

Less likely to seek treatment. Remember the old adage that the person has to want to change. What about individual rights? Some therapists meet with the family and ask them to come to agreement that the person needs treatment and then they confront the AN family member saying, "You need help and we are here to support you. We have made an appointment with Doctor X and so let's go."

More likely to be involved in secrecy about dieting activities.

More likely to have a distorted image of the body, even to the extent of seeming to want to be free of the body. Becoming free of the body and living purely in the mind also happens with highly intellectual people such as, perhaps, Wittenstein, Kierkegaard, Kant, or Heidegger who fostered a life of the mind by simplifying their lives, but that is not the motive of the person with AN. Their motive is to be free of body only and nevermind the mind.

There are also many illogical ideas such as “I must have a perfect body.” It is the presence of such ideas that makes Rational Emotive Therapy or Cognitive Behavior Therapy so appropriate for these people.

Among the consequences of AN are higher mortality rates that are so high that many psychiatrist regard AN as the deadliest disorder. In addition there is bone losss that is so significant that the risk of fracture is doubled. Furthermore, there is dangerously low blood pressure and a high risk for liver and kidney damage.

Additional Eating Disorders

Binge-eating Disorder

This can occur in men as well as women. It seems to come on at a later time in life.

It is a characteristic of many obese people.

There is more psychopathology in these people.

Rumination Disorder

The disorder consists of regurgitating and reswallowing food. It is a disorder of childhood.

In mental retardation it is related to swallowing difficulties in general.

Cause: Biological?

Learned? Gets parental attention.

Behavioral treatment is successful.

Pica

This is the eating of non-nutritive substances, including wallboard or peeling paint with the additional hazard in older houses of the ingestion of lead from the paint.

It is a childhood disorder.

Statistics and Course of Eating Disorders

Bulimia. 90-95% women, but note--some men have the disorder.

Age of onset: 16-19 years.

6-8% of college students meet criteria.

Community surveys have shown a lifetime prevalence of 1.6% for women in general, but for the 18-44 age group it is 4.5%. The prevalence is much lower for women in the 45-64 age group: 0.4%.

Has there been an increase in the prevalence of eating disorders? Probably, but note that diagnosticians have been more aware of the disorder since 1980 when it was first set in the DSM as a psychiatric disorder. I had not encountered a case of eating disorder clinically until sometime in the 1970s. Now it seems to pop up regularly.

Cross Cultural Considerations

There was an Egyptian study that found that women in Cairo universities did not have eating disorders, but Egyptian women who had moved to London did. This suggests that there is something about the local cultural milieu that brings on the disorder.

Chippewa Indian women used purging techniques often. This had ritual significance

Body image disturbances in China are rare. Less common in Japan than in USA, but rates are rising.

Life-Span Developmental Considerations

Causes of Eating Disorders

Social Dimensions

How is beauty defined? How important is it to be physically beautiful? We can speak of the social construction of beauty. The broad dimensions would be developed by the social group, but individual variations would exist within the group.

Much has been made of the influence of the media. It is assumed that effects have been powerful since the 1950s. However, there is a danger in over-emphasized TV as a cause of eating disorders. Research carried out by Eric Stice at UT-Austin showed that long-term exposure to ultra-thin models had no effect on female adolescents, unless they alread had serious concerns about their body image. Girls who had support from family and friends were less susceptible to the influence of thin models. Stice's work does not negate the theory that girls are influenced by media, but it does suggest that the issue is more complex than is generally assumed.

Analyses of Playboy models’ have shown weight changes over the years and the models are now much slimmer.

Cultural and Time-Bound Standards of beauty.

Marilyn Monroe, a star of the 1950s, was definitely curvy.

Renoir painted women as plump and this was an ideal form of the time.

Consider the Greek classical forms. Females and males were neither thin nor chubby. Do they constitute an enduring, universal ideal?

[People wore more clothes, and looser clothes in past. Now, spandex rules and less is hidden.What influence has this had?]

It is clear that today there is less natural exercise: Children walk and exercise less than they did in the past, in part because of fears held by parents that the children will be at risk if they walk or ride bikes to school. This may be an unfounded fear, but it exists. Today, school buses pick children up and take them to and from school. There is a famous Norwegian study that is relevant. It showed that children who lived farther from school were more physically fit than children who lived closer. All walked to school, but in this case, more was better--and fitter.

Family Influences

Some research has shown that the typical anorexic family is hard-driving, competitive, and concerned about external appearances. My question is: how many American families does that leave out? It sounds almost typical, at least for middle and upper class families.

There is another factor: mothers of children with eating disorders were often more concerned about weight. They dieted and this was known to daughters. Again, it seems to be just about typical. Of course, it may be that girls who develop eating disorders are in families that are extreme on these culturally common behaviors.

It is worth noting that we must be careful with generalizations. Most research is based on clinical cases and the family interactions may be reactive to a daughter’s serious condition, and not causal at all.

There is evidence that in some cases there is a history of abusive treatment, but the evidence seems inconsistent and research results are mixed.

Biological Dimensions

Genetic Factors

Eating disorders run in families. They are four to five times as common in some families than others. This may be genetic or environmental. We turn again to twin studes to help clarify the issue:

Concordance Rates

Twins: MZ 30-50%

DZ 10%

Kendler. N =2,163 female twins.

MZ 23%

DZ 9%

Clearly, there is something genetic about these disorders, but what is inherited? Is it a tendency to be obsessive? Is it mpulsivity? Perhaps poor impulse control? Perhaps it is similar to genes that are involved in anxiety disorders.

Psychological Dimensions

There is solid evidence that people with these disorders show a lack of self esteem. This is remarkably true of body self valuation. They also show high social anxiety.

Most people have an accurate sense of their body size and how normal it is. Some people do not, and they see distortions that others do not see. Women who by all physical standards are thin, often see themselves as over-weight. They are fixed in this belief.

Obesity

Obesity seems not to be considered in the textbook as an eating disorder and that is too bad. In the opinion of many public health officials obsesity is an epidemic in the United States. Perhaps it was omitted as a topic because psychology and psychiatry have not done well in developing effective treatments.

In the USA, 35% of women and 31% of men are obese. Obesity raises the risk for hypertension, diabetes, coronary heart disease and sleep apnea. Obese persons also tend to have lower self-esteem, higher rates of disability and earlier retirement.

Obesity is an American phenomenon, but health officials in other countries such as South Africa, are becoming concerned about the increasing problem. In the USA certain ethnic groups have serious problems with weight. These include Hispanics and American Indians, and these groups also have high rates of diabetes..

Many forms of weight loss have been developed and all show some success. The problem is one of keeping the weight off. There is a powerful tendency to regain lost weight. Experts seem to agree that the best things to do are to exercise more and eat less.

For an excellent overview of the problem see www.nytimes.com/obesity. Other websites are

www.aace.com/clin/guides/obestyguide.pdf

www.merck.com/pubs'mmanual/section15/chapter196/196c.htm

www.nhlbi.nih.gov/guidelines/obesity/practgde.pdf

books.nap.edu/books/0309051312html/index.html

www.athealth.com/practitioner/newsletter/FPN_4_16.html

Treatment of Eating Disorders

Drug Treatments

Bulimia.

Anti-depressant medications have some demonstrated efficacy.

Walsh, 1991. Prozac (fluoxetine). n = 382. 65% improved and 27% recovered. Serotonin specific. But note that there were high drop out rates and there was a tendency to revert to earlier behaviors.

Drug treatment is not effective with anorexia nervosa.

Psychosocial Treatments

There was a much quoted study by Minuchin who believed families were enmeshed, that is each knows what the other is thinking, and are over-involved in each others affairs. The adolescent’s push for autonomy presents a problem for these families. The adolescent uses the only control available; how much one eats and weighs . He used family therapy and found a very high improvement rate, but there was no control group or follow-up. He dealt with the ethical problem of treating all or of having some in control group by treating all. In doing this, he involved himself in a more serious ethical problem; that of claiming a treatment is effective when it may not be. He should have had a control group and he should have followed his subjects to see of the early gains were sustained..

Cognitive-behavior therapy was used by Fairburn (1985). Stages: I. Education, physical consequences of behaviors, effectiveness of vomiting etc in weight control (not effective), II. scheduled eating. small amounts 5-6 times per day. III. examination of dysfunctional thoughts and attitudes. Research results: 79-57% effective in recovery. A number of studies now suggest taht cognitive-behavior therapy is the single best method for the treatment of eating disorders. There are good follow-up results. Interpersonal therapy also appears to be good. Furthermore, cogntive behavior therapy and interpersonal therapy are better than behavior therapy alone. Once again we are reminded that in doing effective therapy we must consider how the person thinks.

Todd and associates (1995, Behavior Research and Therapy, 33, 363-367) found cognitive therapy was better than educational therapy in feelings about weight, but both treatments were effective for 63% of the clients.

Cooper et al. (1996, Journal of Psychosomatic Research, 40, 281-287) obtained positive results using self-help manuals with supervison.

The Cochrane group (Whittal, 1999, Behavior Therapy, 30, 117-135) that does research on evidence-based treatment concluded that cognitive behavior therapy was the single most effective treatment for bulimia nervosa. A review by Peterson and Mitchell (1999, Journal of Clinical Psychology, 55, 685-697 came to the same conclusion.

Family therapy that emphasizes education and problem solving is also effective. LaGrange and his group (2000, Journal of Clinical and Consulting Psychology, 41, 727-736) emphasize that it is necessary for the entire family to focus on the eating disorder and be careful to follow all treatment recommendations scrupulously. Parents are to take charge of the eating of their adolescent daughter and let her know that they are in charge. Their results suggest that their family therapy is superior to individual therapy. All of their clients improved.

In an earlier version of this lecture I wrote that we have far to go to find truly effective treatments. It appears now that we have such a treatment. Nevertheless, one of the major problems today is that of the thousands of psychotherapists in the country, only a small proportion are able to use educatinal family therapy or cognitive behavior therapy effectively. This is a short-coming of many of the schools that train therapists. All UH Clinical Psychology Program graduates become highly skillful in the use of cognitive behavior therapy, and this is true of most university-based programs (but not for the professionals schools, and not in the American Northeast, with a few notable exceptions) but this is not the case for most licensed professional practitioners or social worker therapists. Psychiatrists are also not well-trained in this therapy form. We at UH are working now to train students to use the new family therapy.

Self-Help

American Anorexia/Bulimia Association. Teaneck, NJ (201) 836-1800

National Anorexic Aid Society, Columbus, OH (614) 895-2009

National Association of Anorexia and Associated Disorders, Highland Park, IL (312) 831-3438

Anorexics, Bulimics Anonymous, Phoenix, AZ (602) 861-33295

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Sleep...knots up the raveled sleave of care

MacBeth: Shakespeare

Sleep Disorders

The appearance of sleep disorders in abnormal psycholgy textbooks is quite recent. The reason for this is that pepple knew there were sleep disorders, but little was known about them or what to do about them. There was little research and not enough to write about.

In order to make scientific progress it was necessary to obtain some basic information, such as how much sleep is required well-being. Most adults need 8 hours of sleep, but some manage just fine with 5-6 hours, at least for short periods of time. People who regularly sleep more than 8 hours have shorter life spans. Infants sleep 16 hrs/day. Many elderly people require about 6.

It is clear that many Americans do not get enough sleep. They go to bed late and rise to alarm clocks. French people spend more time sleeping. They also spend more time eating. This is a cultural difference.

All of the evidence indicates that it is not wise to be sleep-deprived. Daytime alertness is poor and the immune system functioning is impaired. In a study by Robert Stickgold reported in the February, 2000, Journal of Cognitive Neuroscience it was shown that memory is better after an 8-hour sleep than after shorter sleep lengths. Apparently, sleep strengthens learning associations made while the person is awake. Stickgold and associates have concluded that all-night cramming is a poor practice. It is far better to do the studying earlier and get a good night's sleep before the exam.

Extensive sleep deprivation is associated with impaired mental functioning and psychotic symptoms can result. The main precipitant of manic episodes in bipolar disorder is sleep deprivation. Furthermore, if one regularly has too little sleep a "sleep debt" develops and the person is at increased risk for diabetes because sleep is essential for glucose processing and without sleep there is a rise in blood glucose. High blood pressure is another consequence of sleep deprivation and the immune system does not work well without adequate sleep.

Sleep disorders are associated with other disorders: attention deficit hyperactivity disorder, mood disorders, schizophrenia.

Sleep Research

Research on sleep has been advanced with the discovery of Rapid Eye Movements (REM) and their role in sleep. Baylor College of Medicine in Houston has been a leading sleep research center since the 1960s.

Non Rapid Eyemovement (NREM) sleep has four stages based on different brain EEG patterns which are related to the depth of sleep.

1. Light. Transitional between sleep and wakefulness. This is where Tinkerbell told Peter Pan she would wait for him.

2. Deeper. First true sleep. EEG sleep spindles or K-complexes appear.

3 and 4. Deepest. Delta waves present. Difficult to wake a person from this level of sleep.

A cycle of NREM sleep takes about 90 minutes.

Disorders during this type of sleep: sleepwalking, sleep terrors, sleep bruxism (grinding of teeth). NREM sleep seems related to rebuilding of the immune system.

Go on to REM sleep. Dream time. If a person is wakened during REM sleep, 80% of the time the person will report a dream. Young adults have about 4 REM periods each night. Elderly folks have 3.

Eyes move, but body is atonic, that is, it does not and can not move. Many people have had the experience of dreaming of running away from some threat and not being able to make progress.

When people are deprived of REM sleep by waking them when eye movements are evident, they tend to compensate by entering REM sleep more rapidly and having more REM episodes during subsequent nights. REM sleep is also involved with memory. People especially learn skills involving repetition if they have adequate REM sleep. This includes such things as learning to play the piano, knitting or dancing the tango.

Dyssomnias

Clinical Description

Difficulty in getting enough sleep; not getting to sleep, or not good sleep.

Primary Insomnia

Primary means not related to other medical or psychiatric disorders.

Everyone sleeps some of the time, but people with insomnia have less sleep than they want or need. They have trouble falling asleep, waking frequently, or waking too early.

Statistics

About one-third of the population have some insomnia during a given year. 17% report severe problems.

Causes

Body temperature cycles are altered during sleep. People who do not fall asleep have a delayed temperature rhythm. Their body temperature doesn’t drop. Why not? Perhaps people with going-to-sleep problems would do better in colder bedrooms.

Drug use interferes with sleep and this includes sleep medication. People who drink alcohol to excess repeatedly have sleep problems, commonly awaking at about 4:00am.

When routines are different, as being in a strange place sleep may be disturbed..

Jet lag is a big problem for some people, and no problem at all for others.

Daytime stress is a major cause of disturbed sleep. This is seen in studies showing that anticipation of difficulty is upsetting. Even the expectation of positive events, such as leaving on a much-anticipated vacation trip can interfere with sleep.

People with PTSD often have sleep disturbances.

Poor sleeping may also be a learned behavior. People find they cannot sleep and learn that the bedroom has taken on aversive qualities. Bedtime can become a cause of anxiety.

Primary Hypersomnia

Sleeping too much.

May interfere with driving or work.

Sleep apnea. Breathing problems at night. Interfere with quality of sleep and leads to sleepiness the next day.

Many illnesses including mononucleosis, chronic fatigue syndrome can lead to this.

Narcolepsy

Narcolepsy is daytime sleepiness with catalepsy, which may result in a sudden loss of muscle tone. This can take place in the middle of a conversation or while engaged fully in some task. It affects about 125,000 Americans.

It is related to a sudden onset of REM sleep. The person does not go through stages of sleep, but just goes suddenly into the fully asleep stage.

Sleep paralysis is associated with this disorder. The period after sleep is one inwhich the person unable to function.

Hypnogogic hallucinations may appear. Therse are vivid, terrifying experiences.

Rare: about .03% to .16% of population. No sex difference.

Breathing-Related Sleep Disorders

Breathing is constricted and hypoventilation may occur. Breathing is labored. If the person stops breathing it is sleep apnea. Loud snoring is one sign of the problem.

These disorders are obesity related.

Most common in males (at least, as reported by the females with whom they are sleeping).

Circadian Rhythm Sleep Disorders

These are the rhythms of regulated wake/sleepy cyles. They are coordinated with light which affects the suprachiasmatic nucleus in the hypothalamus. Morning light awakens us. Evening light signals a preparation for sleep.

These disorders are most commonly associated with air travel, that is, rapid travel, across time zones. Most affected are older people, introverted-loners and people who are usual early risers.

Shift work is a problem is a problem if shift changes are made often. This can lead to many other problems including those affecting the gastrointestinal system, ability to concentrate and to solve problems.

The hormone, melatonin, contributes to setting the of biological clocks. Melatonin production is stimulated by darkness and ceases in daylight. However, attempts to counter jet lag with melatonin have not been successful

Treatment of Dysomnias

Medical

Medications, or sleeping pills, are used. These include benzodiazapine drugs, such as triazolam (Halcyon) which is short-acting and flurazepam (Dalmane) which lasts longer. These drugs are addictive and may not be taken for more than short periods of time without possible addictive effects. President Bush (the first) took Halcyon in order to sleep when on overseas trips to counter jet lag. He stopped taking the meds after a bad experience in Japan. Halcyon is banned in 11 countries because of its addictive qualities. In the USA the Institute of Medicine (IOM) recommended its use, but only for short periods of time, not more than 10 days. The IOM pointed out that Halcyon has side effects of extreme confusion and memory loss. It looks like university students might not want to risk taking it.

Diazapine drugs can cause excessive sleepiness and addiction is common. These drugs are safe to use in short-term only. The main symptom of longer use is sleeplessness.

Hypersomnia (sleeping too much) is treated with methlphenidate (Ritalin) or amphetamine, or the old favorite, coffee or some other form of caffeine.

Narcolepsy is treated with Provigil (modafinil). It helps people stay awake without the ups and downs of most stimulants. Help is not inexpensive. The company that makes the pill expects to sell it for about $10.00 a pill.

Behavioral

The patient is instructed to alter circadian rhythms, to sleep later and to use bright lights to adjust the biological clock.

Psychological

See Table 8.3 in your textbook. We can make two additions.

Stimulus Control Therapy. In this the person goes to bed when sleep, uses the bed only for sleep or sex, gets out of bed after 15 minutes of sleeplessness, gets up at the same time each morning and avoids taking day-time naps.

Sleep Hygiene Education. This involves modifying health habits by limiting coffee and alcohol intake, regular exercise and placing limits on noise and other environmental stimulants.

Psychological methods do work and should be used instead of pharmacologic methods whenever possible. One study compared CBT with the medication, Restoril, and found in the 24-month follow-up that the CBT group were doing better. Patients on drugs relapsed when the drugs were discontinued. CBT patients continued to use CBT techneques that they had learned.

In general, for severe and persistent sleep problems it is advisable to seek help at a sleep clinic such as at Baylor College of Medicine.

Parasomnias

Nightmares

These occur during REM or dream sleep. When I was in graduate school one of my fellow students invented the Hanford Nightmare Removal Method (HNRM). His daughter would awaken screaming about monsters in her dreams. Hanford reasoned that in his daughter's opinion her daddy could do anything. Whe she screamed he would rush in and noisily wrestle the nightmare monsters and would throw them out the door with the warning, "Don't you ever bother Caitlin again!" It was highly effective. I tried it with my children and had great success.

Now there is a well-researched variation of this for children and adults with persistent nightmares. University of New Mexico researchers have found that nightmare intensity and frequency can be reduced in a single treatment session. In that session, nightmare sufferers are taught to rewrite their worst dreams with soothing scripts of their own choosing. Then they mentally rehearse these new scripts each day on their own. The new endings need to be reassuring to the dreamer. The use of systematic desensitization (see your textbook) is also effective, but takes about 6 sessions. (Krakow, B., & Neidhardt, J. (1992). Conquering bad dreams and nightmares. Berkeley Press, or Kellner, R. et al. (1992). American Journal of Psychiatry, 149, 659-663.) A student in one of my Abnormal Psychology classes said she had such nightmares and I told her about Krakow's work. She flew to Albuquerque (UNM), was treated in a few days, and never had another nightmare (N = 1, beware)

Sleep Terrors

These usually occur in children and during NREM sleep. They affect about 1% of the adult population. They are not caused by frightening dreams. Do not hold the child or adult--you may be hit. Guide back to bed. If the condition continues past age 14 expert consultation should be sought.

Sleep Walking

This occurs only during NREM sleep. This is not the acting out of a dream. They occur during the deepest stages of sleep. 15-30% of children have at least one episode of sleep walking. Do not wake the sleep walker. Simply guide the person back to bed.

Can killers claim sleep walking as a valid defense? "A 16-year-old Kentucky girl, dreaming that burglars were breaking into her home and murdering her family, got up in her sleep, picked up two revolvers and fired into the dark house, killing her father and 6-year-old brother and injuring her horrified and bewildered mother" (Brody, New York Times, 1/16/96). There are other examples of killing while sleep walking. The girl was acquitted by a jury as were some of the perpetrators, but some were convicted. However, many people sleep walk, but only a rare few commit crimes while asleep.

Dreams

In 1913 Freud wrote that dreams were the royal road to the unconscious. This understanding was of great importance for him because listening to his patients' stories of dreams or their free associations constituted a major part of his work as a psychoanalyst. For many years psychotherapists listened to patients tell their dreams and wondered what they meant. There are problems that have arisen with newer research on sleep. One is that we dream more than once in a night of sleep. Which dream do we interpret? Another is that nearly all dreams never reach conscious awareness and even those that we recall as we awaken tend to disappear too quickly. The patient has to be trained to remember the key dreams.

Why do dreams have such bizarre and puzzling stories? During sleep the frontal lobes and parts of the brain that manage sensory processing such as the visual cortex are inactive. Other parts of the brain, those that control emotions, continue to function and images arise that lack the coherence that would be provided by the frontal lobes. This view of dream function is consistent that sleep is necessary for memory consolidation. The hippocampus is active during dreams and plays a central role in memory formation.

It now seems that dreams are made up of almost random bits of memory, both recent and past, but there are patterns. In a study of 400 Americans, Brazilians and Argentinians, Krippner found national differences. Americans dreamt more about food and animals. Brazilians about sex and emotions. Argentinians dreamt about architecture, aggression and good fortune. There were few gender differences, but some emerged. Men dreamt more about aggression and tools; women dreamt more about children and clothes.

Dream interpretation may be out, but I have found that some clients wanted to talk about their dreams. I encouraged them to do so and then used to contents to lead into cognitive behavioral procedures. "What do you make of that dream?' "How do you feel about it now?" "Why do you think it might be important for you?" Guiding my method was the theory of Medard Boss that dreams are presentations of current issues for the person.

It is clear at this juncture that dreams and dreaming are not well understood. Brain inmaging research will contribute much, but we must also be open to information provided in social and cultural contexts.

Staying Awake

If you must stay awake (e.g., medical residents, armed forces guards, etc.) the best advice for a night with a clear head is to take an afternoon nap, drink two cups of coffee about midnight, and tough it out. Short naps when very sleepy are not as good as a preliminary nap because they interrupt the sleep cycle and cause confusion or grogginess. When the Exxon Valdez went aground on the coast of Alaska spilling thousands of gallons of oil and spoiling the environment the accident was not because the captain had been drinking; it was because the third mate, in charge at the time, was sleep deprived and inattentive.

Resources

National Sleep Foundation. 1367 Connecticut Ave., NW, Dept. NT1, Washington, DC 20036.

Nightmares and disorders of dreaming. www.aafp.org/afp/20000401/2037.html

Helping your child with nightmares. www.athealth.com/consumer/farticles/Siegel.htmnl

Sleep Problems in Children. www.aap.org/family/sleep/htm

Freud's The interpretation of dreams. www.psychwww.com/books/interp/toc.htm

Universal Dreams. www.patriciagarfield.com/publications/udreams_99dreamtime16.htm